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Meta-Analysis
. 2020 May 7:369:m1184.
doi: 10.1136/bmj.m1184.

Prognosis of unrecognised myocardial infarction determined by electrocardiography or cardiac magnetic resonance imaging: systematic review and meta-analysis

Yu Yang  1 , Wensheng Li  2 , Hailan Zhu  2 , Xiong-Fei Pan  3 , Yunzhao Hu  2 , Clare Arnott  4 , Weiyi Mai  5 , Xiaoyan Cai  6 , Yuli Huang  7   4
Affiliations
Meta-Analysis

Prognosis of unrecognised myocardial infarction determined by electrocardiography or cardiac magnetic resonance imaging: systematic review and meta-analysis

Yu Yang et al. BMJ. .

Abstract

Objective: To evaluate the prognosis of unrecognised myocardial infarction determined by electrocardiography (UMI-ECG) or cardiac magnetic resonance imaging (UMI-CMR).

Design: Systematic review and meta-analysis of prospective studies.

Data sources: Electronic databases, including PubMed, Embase, and Google Scholar.

Study selection: Prospective cohort studies were included if they reported adjusted relative risks, odds ratios, or hazard ratios and 95% confidence intervals for all cause mortality or cardiovascular outcomes in participants with unrecognised myocardial infarction compared with those without myocardial infarction.

Data extraction and synthesis: The primary outcomes were composite major adverse cardiac events, all cause mortality, and cardiovascular mortality associated with UMI-ECG and UMI-CMR. The secondary outcomes were the risks of recurrent coronary heart disease or myocardial infarction, stroke, heart failure, and atrial fibrillation. Pooled hazard ratios and 95% confidence intervals were reported. The heterogeneity of outcomes was compared in clinically recognised and unrecognised myocardial infarction.

Results: The meta-analysis included 30 studies with 253 425 participants and 1 621 920 person years of follow-up. UMI-ECG was associated with increased risks of all cause mortality (hazard ratio 1.50, 95% confidence interval 1.30 to 1.73), cardiovascular mortality (2.33, 1.66 to 3.27), and major adverse cardiac events (1.61, 1.38 to 1.89) compared with the absence of myocardial infarction. UMI-CMR was also associated with increased risks of all cause mortality (3.21, 1.43 to 7.23), cardiovascular mortality (10.79, 4.09 to 28.42), and major adverse cardiac events (3.23, 2.10 to 4.95). No major heterogeneity was observed for any primary outcomes between recognised myocardial infarction and UMI-ECG or UMI-CMR. The absolute risk differences were 7.50 (95% confidence interval 4.50 to 10.95) per 1000 person years for all cause mortality, 11.04 (5.48 to 18.84) for cardiovascular mortality, and 27.45 (17.1 to 40.05) for major adverse cardiac events in participants with UMI-ECG compared with those without myocardial infarction. The corresponding data for UMI-CMR were 32.49 (6.32 to 91.58), 37.2 (11.7 to 104.20), and 51.96 (25.63 to 92.04), respectively.

Conclusions: UMI-ECG or UMI-CMR is associated with an adverse long term prognosis similar to that of recognised myocardial infarction. Screening for unrecognised myocardial infarction could be useful for risk stratification among patients with a high risk of cardiovascular disease.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from the National Natural Science Foundation of China, Science and Technology Innovation Project from Foshan, Guangdong, and Shunde Hospital, Southern Medical University for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1
Flow of papers through review. CI=confidence interval; HR=hazard ratio; OR=odds ratio; RR=relative risk; UMI=unrecognised myocardial infarction; UMI-ECG=unrecognised myocardial infarction detected by electrocardiography; UMI-CMR=unrecognised myocardial infarction detected by cardiac magnetic resonance imaging
Fig 2
Fig 2
Forest plot of estimates for risks of primary outcomes associated with unrecognised myocardial infarction detected by electrocardiography. CI=confidence interval; MACE=major adverse cardiac event; MI= myocardial infarction
Fig 3
Fig 3
Forest plot of estimates for risks of secondary outcomes associated with unrecognised myocardial infarction detected by electrocardiography. CHD=coronary heart disease; CI=confidence interval; MI=myocardial infarction
Fig 4
Fig 4
Forest plot of estimates for risks of primary outcomes associated with unrecognised myocardial infarction detected by cardiac magnetic resonance imaging. CI=confidence interval; LGE=late gadolinium enhancement; MACE=major adverse cardiac event; MI=myocardial infarction
Fig 5
Fig 5
Heterogeneity of all cause mortality and cardiac outcomes between unrecognised myocardial infarction and clinically recognised myocardial infarction compared with non-myocardial infarction. CHD=coronary heart disease; MACE=major adverse cardiovascular event; MI=myocardial infarction; RMI=clinically recognised myocardial infarction; UMI=unrecognised myocardial infarction; UMI-ECG=unrecognised myocardial infarction detected by electrocardiography; UMI-CMR=unrecognised myocardial infarction detected by cardiac magnetic resonance imaging
Fig 6
Fig 6
Sensitivity and specificity of electrocardiography for detecting unrecognised myocardial infarction. Cardiac magnetic resonance was regarding as gold standard in this analysis. CI=confidence interval
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